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Avoiding conflicts of interest

If GPs are to remain the public’s ‘superheroes’, they must not get entangled in conflicts of interest under PBC, warns Dr Peter Reader

If GPs are to remain the public's ‘superheroes', they must not get entangled in conflicts of interest under PBC, warns Dr Peter Reader

The NHS has always needed its ‘superheroes'to lead change and reform – and practice-based commissioning is no exception. Many GPs have taken up this latest challenge and seized the powers offered under PBC to redesign pathways of care and shift chunks of acute trust activity into primary care or other novel settings.

But in doing so, many GPs have found themselves in the position of being both commissioners and providers of new models of care. Like some comic-book heroes, this has left GPs open to accusations of acting in a self-serving manner rather than in the wider public interest. So how do GPs show they can manage these new powers responsibly and with probity? Fortunately they don't have to resort to wearing skin-tight latex suits. There is a range of established principles and recommendations that GPs can adopt.


The first line of defence comes from the failing days of the John Major government when a series of scandals undermined confidence in public figures. Out of these emerged the ‘seven principles of public life' – known as the Nolan Principles, named after Lord Nolan, the first chair of the committee on standards in public life.

While most of us will have heard of the principles, few of us have probably considered their day-to-day relevance to general practice. But abiding by them within practices and PBC will help GPs to behave correctly and protect themselves from accusations of self interest.

The Nolan Principles are:

1 Selflessness

Make decisions based solely in the public interest and not for financial or material gain for you, your friends and family.

2 Integrity

Do not place yourself under obligations to external individuals or organisations that might influence your official public duties.

3 Objectivity

Ensure choices on business, contracts, appointments and rewards are based on merit.

4 Accountability

You are accountable for your decisions and must submit yourself to appropriate scrutiny.

5 Openness

Be as open as possible about decisions you make and the reasons behind them.

6 Honesty

You have a duty to declare any private interests relating to public roles, and must take steps to resolve any conflicts of interest.

7 Leadership

You should promote and support these principles by leadership and example.


The second line of defence is to remember that even the best superheroes need a trusted sidekick to work with. It is important to ensure that you undertake your PBC plans, both as a commissioner and a provider, in concert with your local PCT.

PCTs should have robust policies and structures in place to assure that commissioning decisions are taken in a transparent way that provides the best decisions for patients, but that also helps deal with the conflicts of interest that will inevitably arise when GPs act as providers.

It is vital therefore that GPs familiarise themselves with their PCT's policies and ensure they are careful to abide by them and follow due process. I would indeed recommend going further than a cursory read of what may seem turgid documents, and digest them with a detailed and critical eye – check they are robust enough for the job.

This is a new area for everybody and many are struggling, so don't just take it at face value. Sound frameworks of guidance for PCTs were laid out in the NHS Alliance document The Future of Strategic Clinical Leadership in Commissioning and Primary Care, published in July 2006. Its recommendations include:

• all parties should clearly declare any interests

• ensure transparent structures for committees which make recommendations to the PCT board

• consider how the membership of those committees will best manage any conflicts of interest that might arise, for example by appointing a lay chair – usually a non-executive director of the PCT – and ensure members include PCT senior managers to ensure a balance and appropriate debate of issues

• strive for skilled chairing of meetings that are supported by clear and detailed minutes

• members with a declared interest should not take part in discussions, and must leave the room

• PCT boards must receive clear statements of any conflicts of interests and how they have been dealt with and resolved

• establish transparent and robust processes to ensure adequate clinical governance processes and the accreditation and revalidation of GPSIs and their services.

The Department of Health has published its own guidance on these issues, within the PBC practical implementation guidance of November 2006, and recommendations on accrediting GPSIs, published in April this year.


For our final line of defence we can draw another lesson from our superheroes and note that each of them adheres to a moral code in order that they do not abuse their special powers. Let us turn then to our own – theat drawn up by the GMC.

The GMC's Good Medical Practice provides us with five useful top tips for avoiding conflicts of interest.

1 Para 56

Probity means being honest and trustworthy, and acting with integrity: this is at the heart of medical professionalism.

2 Para 57

You must make sure that your conduct at all times justifies your patient's trust in you and the public's trust in the profession.

3 Para 74

You must act in your patients' best interests when making referrals and when providing or arranging treatment or care.

4 Para 75

If you have financial or commercial interests in organisations providing healthcare or in pharmaceutical or other biomedical companies, these interests must not affect the way you prescribe for, treat or refer patients.

5 Para 76

If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest.

When treating NHS patients you must also tell the healthcare purchaser. Doctors consistently top national public opinion polls as the most trusted professionals. By following the principles outlined above when exercising their new PBC powers, they should ensure they retain this elevated status and avoid conflicts of interest.

Dr Peter Reader is a GP and medical director for Islington PCT. He also facilitates the NHS Alliance's national PEC chair network

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